Provider Demographics
NPI:1093748089
Name:VATTASSERIL, RENJY (MD)
Entity Type:Individual
Prefix:
First Name:RENJY
Middle Name:
Last Name:VATTASSERIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 593
Mailing Address - Street 2:
Mailing Address - City:CAPE MAY COURT HOUSE
Mailing Address - State:NJ
Mailing Address - Zip Code:08210-0593
Mailing Address - Country:US
Mailing Address - Phone:609-463-2755
Mailing Address - Fax:609-463-2757
Practice Address - Street 1:217 N MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CAPE MAY COURT HOUSE
Practice Address - State:NJ
Practice Address - Zip Code:08210-2165
Practice Address - Country:US
Practice Address - Phone:609-536-8010
Practice Address - Fax:609-536-8053
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239444207R00000X
NJ25MA08709900207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP01227607OtherRAILROAD MEDICARE
NJ0232475Medicaid
NJP01227607OtherRAILROAD MEDICARE